Healthcare Provider Details

I. General information

NPI: 1154760312
Provider Name (Legal Business Name): SAMANTHA FUGATE KENNEDY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA ANN FUGATE

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FEE RD STE B119
EAST LANSING MI
48824
US

IV. Provider business mailing address

804 SERVICE RD # A109F
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-353-3070
  • Fax: 517-432-3603
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5101020751
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: